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ST-segment elevation (STE) in patients with COVID-19 has raised novel issues in diagnosis and management. In this case series from six New York City hospitals, investigators shared their experience with 18 patients with STE who presented during the first month of the pandemic.
The median age was 63, and 83% were male; 50% were Hispanic, 22% white, 17% Asian, and 11% black. Most patients had underlying cardiac risk factors. About half had STE at presentation, whereas the others had STE at a median of 6 days after hospitalization. Only 33% presented with chest pain; 83% had respiratory symptoms (cough, shortness of breath, or respiratory distress).
The 10 patients with nonobstructive coronary artery disease (CAD) on angiography or without wall motion abnormalities on echocardiography were likely to have diffuse STE. Patients with myocardial infarction (MI) had higher median troponin T levels (mean, 6.3 ng/mL) than those with noncoronary myocardial injury (mean, 0.02 ng/mL). Five patients underwent percutaneous coronary intervention (PCI). Thirteen patients (72%) died in the hospital; nine had noncoronary myocardial injury, and four had MI.
Bangalore S et al. ST-segment elevation in patients with Covid-19 — A case series. N Engl J Med 2020 Apr 17; [e-pub]. (https://doi.org/10.1056/NEJMc2009020)
Comment
Although this series is a small and early snapshot of COVID-19 patients with STE, several key considerations for diagnosis and management are apparent. Patients with STE are more likely to be male and Hispanic, have a high prevalence of nonobstructive CAD (with a much lower troponin T level), but overall still have a poor prognosis. The combination of focal STE with regional wall motion abnormalities or reduced ejection fraction was linked to obstructive CAD and PCI. In patients with STE, the complex interplay of cytokine storm, hypoxic injury, microthrombi, plaque rupture, and direct vascular injury, all of which occur in COVID-19 illness, will continue to challenge cardiologists to identify true STEMI patients who could benefit from an invasive assessment.